- Kristy A Bauman, MD
Kristy A Bauman, MD
- Assistant Professor of Medicine
- University of Michigan Medical Center
- Robert C Hyzy, MD
Robert C Hyzy, MD
- Associate Professor of Medicine
- University of Michigan Medical Center
Extubation refers to removal of the endotracheal tube (ETT). It is the final step in liberating a patient from mechanical ventilation. Issues that need to be considered prior to extubation, the extubation procedure itself, and management after extubation are described here. Outcomes following extubation are also discussed. Predictors of weaning success and methods of weaning from mechanical ventilation are reviewed separately. (See "Weaning from mechanical ventilation: Readiness testing" and "Methods of weaning from mechanical ventilation".)
PRIOR TO EXTUBATION
At the end of the weaning process, it may be apparent that a patient no longer requires mechanical ventilation to maintain sufficient ventilation and oxygenation. However, extubation should not be ordered until it has been determined that the patient is able to protect the airway and the airway is patent.
Airway protection — Airway protection is the ability to guard against aspiration during spontaneous breathing. It requires sufficient cough strength and an adequate level of consciousness, each of which should be assessed prior to extubation. The amount of secretions should also be considered prior to extubation because airway protection is significantly more difficult when secretions are increased.
Extubation failure is highest when a combination of risk factors is present. As an example, when reduced cough peak expiratory flow rate (≤60 L/min), increased sputum volume (>2.5 mL/hr), and impaired neurologic function (inability to follow commands) are present, the incidence of extubation failure was 100 percent, compared to 3 percent when none of the risk factors were present (relative risk 23, 95% CI 3.2-167) .
Universally accepted threshold levels of cough strength, level of consciousness, and suctioning frequency that prohibit extubation have not been established. For many patients, it seems reasonable to delay extubation if the cough strength is weak, the GCS is <8, or suctioning is required more frequently than every two to three hours. However, the final decision to delay or proceed with extubation should be made on a case-by-case basis since delayed extubation is associated with adverse outcomes, such as ventilator-associated pneumonia and increased length of stay .
- Salam A, Tilluckdharry L, Amoateng-Adjepong Y, Manthous CA. Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med 2004; 30:1334.
- Coplin WM, Pierson DJ, Cooley KD, et al. Implications of extubation delay in brain-injured patients meeting standard weaning criteria. Am J Respir Crit Care Med 2000; 161:1530.
- Khamiees M, Raju P, DeGirolamo A, et al. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest 2001; 120:1262.
- Beuret P, Roux C, Auclair A, et al. Interest of an objective evaluation of cough during weaning from mechanical ventilation. Intensive Care Med 2009; 35:1090.
- Thille AW, Boissier F, Ben Ghezala H, et al. Risk factors for and prediction by caregivers of extubation failure in ICU patients: a prospective study. Crit Care Med 2015; 43:613.
- Epstein SK. Putting it all together to predict extubation outcome. Intensive Care Med 2004; 30:1255.
- Smina M, Salam A, Khamiees M, et al. Cough peak flows and extubation outcomes. Chest 2003; 124:262.
- Namen AM, Ely EW, Tatter SB, et al. Predictors of successful extubation in neurosurgical patients. Am J Respir Crit Care Med 2001; 163:658.
- Maury E, Guglielminotti J, Alzieu M, et al. How to identify patients with no risk for postextubation stridor? J Crit Care 2004; 19:23.
- Kriner EJ, Shafazand S, Colice GL. The endotracheal tube cuff-leak test as a predictor for postextubation stridor. Respir Care 2005; 50:1632.
- Sukhupanyarak S. Risk factors evaluation and the cuff leak test as predictors for postextubation stridor. J Med Assoc Thai 2008; 91:648.
- Cheng KC, Hou CC, Huang HC, et al. Intravenous injection of methylprednisolone reduces the incidence of postextubation stridor in intensive care unit patients. Crit Care Med 2006; 34:1345.
- François B, Bellissant E, Gissot V, et al. 12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial. Lancet 2007; 369:1083.
- Santos PM, Afrassiabi A, Weymuller EA Jr. Risk factors associated with prolonged intubation and laryngeal injury. Otolaryngol Head Neck Surg 1994; 111:453.
- Friedman M, Baim H, Shelton V, et al. Laryngeal injuries secondary to nasogastric tubes. Ann Otol Rhinol Laryngol 1981; 90:469.
- Miller RL, Cole RP. Association between reduced cuff leak volume and postextubation stridor. Chest 1996; 110:1035.
- Jaber S, Chanques G, Matecki S, et al. Post-extubation stridor in intensive care unit patients. Risk factors evaluation and importance of the cuff-leak test. Intensive Care Med 2003; 29:69.
- De Bast Y, De Backer D, Moraine JJ, et al. The cuff leak test to predict failure of tracheal extubation for laryngeal edema. Intensive Care Med 2002; 28:1267.
- Lee CH, Peng MJ, Wu CL. Dexamethasone to prevent postextubation airway obstruction in adults: a prospective, randomized, double-blind, placebo-controlled study. Crit Care 2007; 11:R72.
- Ochoa ME, Marín Mdel C, Frutos-Vivar F, et al. Cuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis. Intensive Care Med 2009; 35:1171.
- Fisher MM, Raper RF. The 'cuff-leak' test for extubation. Anaesthesia 1992; 47:10.
- Engoren M. Evaluation of the cuff-leak test in a cardiac surgery population. Chest 1999; 116:1029.
- Ding LW, Wang HC, Wu HD, et al. Laryngeal ultrasound: a useful method in predicting post-extubation stridor. A pilot study. Eur Respir J 2006; 27:384.
- Sutherasan Y, Theerawit P, Hongphanut T, et al. Predicting laryngeal edema in intubated patients by portable intensive care unit ultrasound. J Crit Care 2013; 28:675.
- Mort TC. Continuous airway access for the difficult extubation: the efficacy of the airway exchange catheter. Anesth Analg 2007; 105:1357.
- Darmon JY, Rauss A, Dreyfuss D, et al. Evaluation of risk factors for laryngeal edema after tracheal extubation in adults and its prevention by dexamethasone. A placebo-controlled, double-blind, multicenter study. Anesthesiology 1992; 77:245.
- Ho LI, Harn HJ, Lien TC, et al. Postextubation laryngeal edema in adults. Risk factor evaluation and prevention by hydrocortisone. Intensive Care Med 1996; 22:933.
- Khemani RG, Randolph A, Markovitz B. Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults. Cochrane Database Syst Rev 2009; :CD001000.
- Fan T, Wang G, Mao B, et al. Prophylactic administration of parenteral steroids for preventing airway complications after extubation in adults: meta-analysis of randomised placebo controlled trials. BMJ 2008; 337:a1841.
- McCaffrey J, Farrell C, Whiting P, et al. Corticosteroids to prevent extubation failure: a systematic review and meta-analysis. Intensive Care Med 2009; 35:977.
- Jaber S, Jung B, Chanques G, et al. Effects of steroids on reintubation and post-extubation stridor in adults: meta-analysis of randomised controlled trials. Crit Care 2009; 13:R49.
- Cheng KC, Chen CM, Tan CK, et al. Methylprednisolone reduces the rates of postextubation stridor and reintubation associated with attenuated cytokine responses in critically ill patients. Minerva Anestesiol 2011; 77:503.
- Tischenkel BR, Gong MN, Shiloh AL, et al. Daytime Versus Nighttime Extubations: A Comparison of Reintubation, Length of Stay, and Mortality. J Intensive Care Med 2016; 31:118.
- Tiruvoipati R, Lewis D, Haji K, Botha J. High-flow nasal oxygen vs high-flow face mask: a randomized crossover trial in extubated patients. J Crit Care 2010; 25:463.
- Maggiore SM, Idone FA, Vaschetto R, et al. Nasal high-flow versus Venturi mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome. Am J Respir Crit Care Med 2014; 190:282.
- Nava S, Gregoretti C, Fanfulla F, et al. Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med 2005; 33:2465.
- Ferrer M, Valencia M, Nicolas JM, et al. Early noninvasive ventilation averts extubation failure in patients at risk: a randomized trial. Am J Respir Crit Care Med 2006; 173:164.
- El-Solh AA, Aquilina A, Pineda L, et al. Noninvasive ventilation for prevention of post-extubation respiratory failure in obese patients. Eur Respir J 2006; 28:588.
- Ferrer M, Sellarés J, Valencia M, et al. Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet 2009; 374:1082.
- Burns KE, Meade MO, Premji A, Adhikari NK. Noninvasive positive-pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Cochrane Database Syst Rev 2013; 12:CD004127.
- Girault C, Bubenheim M, Abroug F, et al. Noninvasive ventilation and weaning in patients with chronic hypercapnic respiratory failure: a randomized multicenter trial. Am J Respir Crit Care Med 2011; 184:672.
- Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 2004; 350:2452.
- Keenan SP, Powers C, McCormack DG, Block G. Noninvasive positive-pressure ventilation for postextubation respiratory distress: a randomized controlled trial. JAMA 2002; 287:3238.
- Epstein SK, Ciubotaru RL. Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. Am J Respir Crit Care Med 1998; 158:489.
- Razek T, Gracias V, Sullivan D, et al. Assessing the need for reintubation: a prospective evaluation of unplanned endotracheal extubation. J Trauma 2000; 48:466.
- Krinsley JS, Barone JE. The drive to survive: unplanned extubation in the ICU. Chest 2005; 128:560.
- Epstein SK, Nevins ML, Chung J. Effect of unplanned extubation on outcome of mechanical ventilation. Am J Respir Crit Care Med 2000; 161:1912.
- de Larminat V, Montravers P, Dureuil B, Desmonts JM. Alteration in swallowing reflex after extubation in intensive care unit patients. Crit Care Med 1995; 23:486.
- Coppolo DP, May JJ. Self-extubations. A 12-month experience. Chest 1990; 98:165.
- Vassal T, Anh NG, Gabillet JM, et al. Prospective evaluation of self-extubations in a medical intensive care unit. Intensive Care Med 1993; 19:340.
- Listello D, Sessler CN. Unplanned extubation. Clinical predictors for reintubation. Chest 1994; 105:1496.
- Tindol GA Jr, DiBenedetto RJ, Kosciuk L. Unplanned extubations. Chest 1994; 105:1804.
- Betbesé AJ, Pérez M, Bak E, et al. A prospective study of unplanned endotracheal extubation in intensive care unit patients. Crit Care Med 1998; 26:1180.
- Boulain T. Unplanned extubations in the adult intensive care unit: a prospective multicenter study. Association des Réanimateurs du Centre-Ouest. Am J Respir Crit Care Med 1998; 157:1131.
- Chevron V, Ménard JF, Richard JC, et al. Unplanned extubation: risk factors of development and predictive criteria for reintubation. Crit Care Med 1998; 26:1049.
- de Lassence A, Alberti C, Azoulay E, et al. Impact of unplanned extubation and reintubation after weaning on nosocomial pneumonia risk in the intensive care unit: a prospective multicenter study. Anesthesiology 2002; 97:148.
- Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA 2002; 287:345.
- Curry K, Cobb S, Kutash M, Diggs C. Characteristics associated with unplanned extubations in a surgical intensive care unit. Am J Crit Care 2008; 17:45.
- Chang LY, Wang KW, Chao YF. Influence of physical restraint on unplanned extubation of adult intensive care patients: a case-control study. Am J Crit Care 2008; 17:408.
- Moons P, Sels K, De Becker W, et al. Development of a risk assessment tool for deliberate self-extubation in intensive care patients. Intensive Care Med 2004; 30:1348.
- Frutos-Vivar F, Ferguson ND, Esteban A, et al. Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest 2006; 130:1664.
- Thille AW, Harrois A, Schortgen F, et al. Outcomes of extubation failure in medical intensive care unit patients. Crit Care Med 2011; 39:2612.
- Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome of mechanical ventilation. Chest 1997; 112:186.
- Torres A, Gatell JM, Aznar E, et al. Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med 1995; 152:137.
- Rady MY, Ryan T. Perioperative predictors of extubation failure and the effect on clinical outcome after cardiac surgery. Crit Care Med 1999; 27:340.
- Reyes A, Vega G, Blancas R, et al. Early vs conventional extubation after cardiac surgery with cardiopulmonary bypass. Chest 1997; 112:193.